P1631: A RETROSPECTIVE STUDY OF PATIENTS WITH BRUISING REFERRED TO A CLOTTING DISORDERS CLINIC IN A DISTRICT GENERAL HOSPITAL IN UK
Authors: Leila Khalil
Journal: HemaSphere (2023)

Topic: 33. Bleeding disorders (congenital and acquired) Background: Bruising is a common complaint. There is no diagnostic pathway to follow for those presenting with chronic bruising as their chief complaint. There is a massive pressure on national health service in the UK and an urgent need to create diagnostic pathways for common complaints where possible as well as reducing inappropriate or unnecessary laboratory testing. North West Anglia NHS Foundation Trust serves a population of around 800.000 Aims: Establish cause of bruising, explore most appropriate diagnostic tests and select patients for specialist testing. Methods: Electronic records of patients (16 years or over) who were referred to the clotting disorders clinic in our hospital between January 2016 and May 2022 were reviewed. All the referrals were routine (non -urgent). The clinic is run by one haematology consultant with an interest in haemostasis. Assessment included history and examination, ISTH BAT, Coagulation screen (PT, APTT, fibrinogen), Von Willebrand disease screen as baseline tests in addition to coagulation factors, protein electrophoresis, thyroid function tests, platelet function studies (aggregation and nucleotide release) where appropriate and rarely genetic testing Results: Fifty adult patients (16 years or over) were referred. Data were missing for 4 patients. Forty six patients’ records were reviewed. All patients were females. The majority (64%) were between the ages of 20-40, 18% were between 41-60 years, 16 % over 60 and 2 % were below 20 years. Fifty nine percent of patients had concomitant bleeding symptoms mainly menorrhagia. ISTH BAT was normal (less than 6) in 80% of patients. Only 7% had a positive family history for bleeding but with no established diagnosis. No cause was found in 48% of patients. Bruising resolved spontaneously in 9% of patients. Six percent were lost to follow up. A potential cause for bruising was identified in 37% of patients. The commonest diagnoses were psychogenic purpura (5) and senile purpura (4). Other diagnoses included borderline VWD levels (1), mild factor deficiency (2), Ehlers-Danlos (1), unclassified bleeding disorder (1) and borderline fibrinogen levels (1.7- 1.8 g/l) (3). Normal fibrinogen level in our laboratory is 2-4.5 g/l Platelet function tests were requested in 28 % of patients. Results were within normal limits in 90% of patients. Genetic tests were requested for 2 patients with high ISTH BAT and abnormal platelet studies but genetic testing was inconclusive. Fifteen percent of the whole cohort were on Aspirin and/or NSAID. Thirty three percent were taking SSRI (Fluoxetine, Citalopram or Sertraline) Summary/Conclusion: All patients were females. It is well established that females bruise more easily than males. This is attributed to effect of oestrogen on vessels and reduced collagen in the skin. The study showed that basic coagulation tests (PT, APTT, fibrinogen and VWD screen) available in primary care will detect most patients with a bleeding disorder. Platelet function studies may be helpful in patients with high ISTH BAT. Almost half the patients referred to our clinic with bruising did not have an underlying bleeding disorder. Effect of medications particularly antiplatelet agents, NSAIDS and SSRIs should be explored in all patients before specialist referral or investigations. Psychogenic purpura is an important cause of extensive purpura and probably not as rare as the literature suggests. Keywords: Bleeding disorder, Female, Coagulation factors, Blood coagulation